Juxtarenal Aortic Pseudoaneurysm - Right Renal Vein Fistula with Circumaortic Renal Collar-Delayed Manifestation of a Gunshot Injury - an Uncommon Entity Diagnosed with CT Angiography.

BACKGROUND: Delayed presentation of post-traumatic aortic pseudoaneurysm and its fistulous communication with the right renal vein is a very rare entity. Most of the cases described in literature are due to abdominal aortic aneurysm (AAA) rupture into the left renal vein. To the best of our knowledge, communication with the right renal vein has not been described in published literature. Our patient also had a circumaortic renal collar, which is a rare renal vein anomaly. Aortic pseudoaneurysm, its fistulous communication with the right renal vein and circumaortic renal collar in a single patient is of extremely rare occurrence. CASE REPORT: A 29-year-old male presented to the cardiology department with complaints of breathlessness, abdominal pain and hematuria for the last 6 months. On clinical examination there was evidence of audible bruit over the abdomen. He had a past history of a gunshot injury around two years back. CT angiography revealed a large partially calcified pseudoaneurysm arising from the right lateral wall of the abdominal aorta with the neck of the pseudoaneurysm at juxtarenal location with a fistula between the anterior wall of the pseudoaneurysm and the posterior wall of the right renal vein. There was an associated incidental finding of circumaortic left renal vein with gross aneurysmal dilatation of both pre- and retro-aortic part of the renal vein. CONCLUSIONS: Delayed presentation of aortic pseudoaneurysm with its fistulous communication with the right renal vein is a rare entity. CT angiography is a non-invasive modality for diagnosis of the exact site of communication, length of aneurysm, proximal and distal extent of the affected segment and its relationship with surrounding structures.

Serum endotoxin, inflammatory mediators, and magnetic resonance spectroscopy before and after treatment in patients with minimal hepatic encephalopathy.

BACKGROUND: Minimal hepatic encephalopathy (MHE) represents the mildest form of hepatic encephalopathy (HE), with abnormal neuropsychologic findings. Inflammatory response may be important in the pathogenesis of MHE. On magnetic resonance spectroscopy (MRS), improvement of metabolic ratios after liver transplantation suggests an important role of myoinositol (mI) and choline (cho) in the development of MHE. AIMS: To investigate arterial ammonia, tumor necrosis factor alpha (TNF-α), interleukin (IL)-6, IL-18, serum endotoxin, and MRS before and after treatment in MHE. PATIENTS AND METHODS: Sixty patients of cirrhosis with MHE were randomized to two groups, Gr. MHE-L (n = 30), treated with lactulose for 3 months, and Gr. MHE-NL (n = 30), who did not received lactulose. Arterial ammonia, TNF-α, IL-6, IL-18, serum endotoxin, and MRS were performed in all patients at baseline and at 3 months and 20 patients of cirrhosis without MHE and 20 healthy controls. RESULTS: After 3 months, median arterial ammonia (69.4 vs 52.7 mcg/dL), TNF-α (26.6 vs 22 pg/mL), IL-6 (17.6 vs 12.4 pg/mL), IL-18 (42.5 vs 29 pg/mL), and serum endotoxin (0.68 vs 0.43 EU/mL) significantly decreased in Gr. MHE-L compared with baseline (P < 0.0001), while no change was seen in Gr. MHE-NL patients. On MRS, compared with patients of cirrhosis without MHE, mI and cho were significantly lower (P < 0.001) and glutamine (Glx) was significantly higher in both MHE groups (P < 0.001). After 3 months, mI and cho increased and Glx decreased significantly in Gr. MHE-L (P < 0.001), without changes in Gr. MHE-NL patients. Psychometric hepatic encephalopathic score (PHES) correlated well with arterial ammonia, TNF-α, IL-6, IL-18, serum endotoxin, and metabolic parameters on MRS. CONCLUSIONS: Arterial ammonia, inflammatory mediators (TNF-α, IL-6, IL-18), and serum endotoxin reduce and MRS abnormalities improve after treatment with lactulose in patients with MHE.

Papillary Adenocarcinoma in a Gastric Duplication Cyst.

Gastric duplication cysts are rare and mostly present in the first year of life. In adulthood presentation is in the form of obstruction, ulceration, bleeding, fistulization etc. Malignancy is extremely rare with only 12 cases reported to date. We came across a gastric duplication cyst with papillary adenocarcinoma in a 63 year old man. He underwent cyst excision with radical subtotal gastrectomy. The awareness of such a condition made it possible for us to have a suspicion of malignancy preoperatively based on imaging and thus a radical surgery was performed. High index of suspicion is necessary to diagnose this condition preoperatively on CT scan. Literature review revealed that this is the first case to be reported from India.

Segmental dilatation of ileum in a young patient presenting with anemia.

Segmental dilatation of ileum (SDI) is a less known uncommon entity with a confusing clinical scenario and no definite etiopathogenesis. The preoperative diagnosis is of exclusion. However, it has an excellent prognosis after surgery. We describe a case of a young patient who presented with anemia without any overt gastrointestinal (GI) bleed. Thorough radiological examinations were needed to reach the diagnosis of SDI which was confirmed postoperatively.

Osteochondroma Complicated by a Popliteal Vein Aneurysm- A Rare Case Report.

Osteochondroma is the most common benign skeletal tumour. It frequently causes pain and local symptoms, however, vascular complications are rare. The popliteal artery is more commonly affected and there are isolated case reports of popliteal artery pseudoaneurysm in literature. However, venous complications are extremely rare. We hereby report a case of 21-year-old male patient with distal femoral osteochondroma complicated by a popliteal venous aneurysm and deep vein thrombosis. This association has not been described in the past. The patient was put on anticoagulants as he refused surgery and was asymptomatic at six months follow-up. Awareness of this complication is important for timely diagnosis and surgical management as it is a source of life threatening pulmonary thromboembolism.

Fibrosing mediastinitis: when to suspect and how to evaluate?

Fibrosing mediastinitis (FM), which is also known as mediastinal fibrosis or sclerosing mediastinitis, is an uncommon, benign and progressive condition characterized by an invasive proliferation of fibrous tissue within the mediastinum. Tuberculosis and histoplasmosis are the major causes of the granulomatous variety, while non-granulomatous FM is an idiopathic reaction to autoimmune syndromes, drugs and radiation. Contrast-enhanced CT is the investigation of choice that can diagnose, and assess the extent and the severity of involvement. We are presenting a case of FM in a young female who presented with complaints of breathlessness, occasional cough and diffuse chest pain for 3 months.

The "frosted liver" appearance in hepatic tuberculosis: a rare presentation.

Tuberculosis is a major re-emerging global health concern. The disease may involve any body system and is a great mimicker of various pathologies owing to its non-specific imaging findings. Herein we report an extremely rare case of atypical tuberculosis of the liver in a young female with complaints of abdominal pain and haematemesis for 10 weeks. Isolated hepatic tuberculosis is a rare entity with < 100 cases reported in the literature. It is therefore important to have a high index of suspicion and be familiar with the atypical imaging findings of abdominal tuberculosis. This discussion highlights the clinical presentation, imaging findings and types of hepatic involvement in tuberculosis.

A Case of Coronary Cameral Fistula with Associated Aneurysm: Role of ECG Gated 256- Slice Dual Source Multidetector Computed Tomography in Diagnosis.

We report an interesting case of coronary cameral fistula with associated aneurysmal dilatation of coronary artery. The complete evaluation including anatomical relationships with surrounding vascular and non-vascular structures can be achieved with ECG gated multi-detector computed tomography (MDCT). MDCT has many advantages over echocardiography and digital subtraction catheter angiography, because of its ability to demonstrate the fistula separate from surrounding cardiovascular structures along with any aneurysm or obstruction in its course. Thus, MDCT is emerging as the initial non-invasive imaging technique for comprehensive preoperative evaluation of these rare congenital anomalies for cardiovascular surgeons to achieve better operative assessibity and outcome.

Percutaneous thrombin injection under sonographic guidance for exclusion of non-catheterizable post-pancreatitis pseudoaneurysm of the superior mesenteric artery: a minimally invasive and expeditious treatment option.

Post-pancreatitis pseudoaneurysms are not uncommon. They have a high associated mortality due to a propensity to rupture. Current standards of treatment advocate immediate intravascular interventions. We describe two cases of alcohol-related post-acute pancreatitis pseudoaneurysms arising from the second-order branches of the superior mesenteric artery (SMA) that were endoluminally inaccessible. Both cases were successfully treated with percutaneous thrombin injection into the pseudoaneurysm sac under ultrasound guidance. We suggest that endoluminally inaccessible pseudoaneurysms that are percutaneously accessible can be expeditiously treated with percutaneous thrombin injection. Further, due to the efficaciousness of this procedure, it could be considered as a first-line minimally invasive therapeutic option.

Buthionine sulfoximine increases the efficacy of arteether antimalarial activity in arteether-resistant Plasmodium vinckei by glutathione depletion.

Background: L-buthionine (S,R)-sulfoximine (BSO) regulates the glutathione (GSH) level, which in turn exhibits remarkable regulation of several important aspects of cellular metabolism. We hypothesised that increasing the cellular levels of glutathione leads to an increased resistance to arteether, whereas decreasing these by using a GSH inhibitor increases the parasite sensitivity to arteether in the rodent malaria parasite Plasmodium vinckei. Materials and Methods: We tested in vivo effects of BSO on GSH and hemozoin formation in arteether-sensitive and - resistant strains. Experimental groups of 7-8 Swiss mice were inoculated by intraperitoneal injection (i.p.) with 1×106 parasitized erythrocytes of PvAS (sensitive) or PvAR (resistant) strain of P. vinckei. The infected mice were treated with BSO (Sigma) 400 mg/kg twice a day for four days and blood was collected after the last injection with BSO. Results: A relatively stronger inhibition of GSH level was observed in the blood of mice infected with resistant parasites (62.64%; p<0.0001), whereas inhibition in sensitive strain-infected mice and uninfected mice was 32% (p=0.034) and 35% (p=0.034), respectively. The results also show an inverse relationship between GSH and hemozoin in the arteether-sensitive and -resistant strains. The hemozoin contents in the resistant strain are 0.27±0.09, 0.69±0.14 and 5.30±0.79 µmol/109 cells at 5, 10 and 20% parasitemia, respectively, whereas hemozoin contents in the sensitive strain at the same parasitemia levels are 0.59±0.29, 12.38±1.96 and 30.80±2.27 µmol/109 cells. Moreover, hemozoin formation increased by 80% through the administration of BSO in the arteether-resistant strain, whereas insignificant changes occurred in the sensitive strain. BSO was also found to increase the efficacy of arteether antimalarial activity against the resistant strain in vivo. Conclusions: Treatment with BSO significantly reduces the level of GSH, which leads to insufficient growth of resistant parasites. These results suggest that BSO might be helpful in prolonging the persistence of the drug, and pose a promising lead to help reducing the chance of resistance development against artemisinin and its derivatives.

Comprehensive Evaluation of Cardiac Hydatid Using 256 Slice Dual Source CT: One Stop Shop.

Hydatid disease results from infection with larval stage of Echinococcus granulosus tapeworm. Dogs and other canines are the definitive hosts; Human beings are common accidental intermediate hosts. Liver is the most common organ to be involved in this condition. Cardiac hydatid, seen in only 0.5 to 2% cases, is a rare entity because of myocardial contractility. Larvae reach the myocardium through coronary circulation. Among various locations of cardiac hydatid, due to its rich coronary arterial supply Left ventricle (LV) myocardium is the most common site of involvement followed by interventricular septum and right ventricle. Rare locations include pericardium, right atrium and left atrium. A 50-year-old woman presented with dyspnoea for 11 months, chest X-ray showed a well defined, homogenous left paracardiac mass, which is not separable from left heart border. Transthoracic echocardiography revealed a complex multicystic mass lesion abutting antero-lateral wall of left ventricle. Contrast enhanced computed tomography showed a well-circumscribed multicystic mass lesion with honeycomb appearance arising from myocardium of anterolateral wall of left ventricle. Indirect haemagglutination test for hydatid disease was positive. At surgery the cyst was seen to arise from LV myocardium. It was incised and grape like contents were evacuated. The cavity was irrigated with scolicidal solution. Thereafter, the cyst was marsupialised. Histopathological examination revealed grape like cyst contents consistent with the diagnosis of hydatid cyst.

Coarctation of the aorta with left pulmonary artery stenosis: a rare association diagnosed with ECG-gated multislice dual-source CT angiography.

We report an extremely rare case of coarctation of the aorta with associated left pulmonary artery stenosis. This violates the traditional fetal flow pattern theory. Two-dimensional echocardiography, although being the initial imaging modality for diagnosing coarctation of the aorta, is limited in the demonstration of branch pulmonary arteries. Retrospective ECG-gated multidetector CT angiography is a non-invasive imaging technique for comprehensive assessment of the site, length and severity of the stenosed aortic segment. It is also helpful in differentiation of an interrupted aortic arch from severe coarctation. Associated pulmonary arterial and venous system anomalies can be evaluated, which dictates the management of aortic coarctation.

DNA prime-protein boost immunization in monkeys: efficacy of a novel construct containing functional domains of Plasmodium cynomolgi CS and TRAP.

We report the efficacy of a bimodal immunization regimen that involved priming with naked DNA (multiple doses) followed by a booster with recombinant protein in rhesus monkeys with a chimeric construct containing the N-terminus of thrombospondin-related adhesive protein and the C-terminus of circumsporozoite protein of Plasmodium cynomolgi. The vaccinated animals developed high titer antibodies against the chimeric antigen, the two components of the hybrid and the native proteins of sporozoites. The peripheral blood mononuclear cells isolated from the vaccinated animals had significant in vitro T cell proliferation activity when stimulated with the recombinant chimeric protein. Furthermore, following challenge with 1000 P. cynomolgi sporozoites, the peak and total parasitemia were significantly lower in vaccinated animals than in the control animals.

Immunogenicity and protective efficacy of three DNA vaccines encoding pre-erythrocytic- and erythrocytic-stage antigens of Plasmodium cynomolgi in rhesus monkeys.

Although several malaria vaccine candidate antigens have been identified, the most suitable methods for their delivery are still being investigated. In this regard, direct immunization with DNA encoding these vaccine target antigens is an attractive alternative. Here, we have investigated the immune responses to DNA immunization with three major vaccine target antigens: the apical membrane antigen-1 and the 19-kDa C-terminal fragment of merozoite surface protein-1 from the erythrocytic stage, and the thrombospondin-related adhesive protein from the pre-erythrocytic stage of Plasmodium cynomolgi in rhesus monkeys. Antigen-specific antibodies were developed in all the immunized monkeys and peripheral blood mononuclear cells from all immunized monkeys proliferated to different extents upon in vitro stimulation with the corresponding recombinant proteins. The immunized monkeys were challenged with P. cynomolgi sporozoites. All of the immunized animals developed infection but although there was no significant difference between the control and vaccinated animals in terms of pre-patent period, total duration of patency and primary peak parasitemia, the vaccinated animals had significantly lower secondary peak parasitemia than the control animals.

'Primary extrarenal Wilms' tumour': rare presentation of a common paediatric tumour.

Wilms' tumour (nephroblastoma), the most common abdominal malignancy of childhood, occurs primarily as a malignant renal tumour. Extrarenal Wilms' tumour is rare with occasional reports from the Indian subcontinent. The various locations of extrarenal Wilms' tumour include retroperitoneum, uterus, skin and thorax. In this report we will discuss the imaging features highlighting the imaging differential diagnosis in a case of retroperitoneal (extrarenal) primary Wilms' tumour.

Synthesis and insight into the structure-activity relationships of chalcones as antimalarial agents.

Licochalcone A (I), isolated from the roots of Chinese licorice, is the most promising antimalarial compound reported so far. In continuation of our drug discovery program, we isolated two similar chalcones, medicagenin (II) and munchiwarin (III), from Crotalaria medicagenia , which exhibited antimalarial activity against Plasmodium falciparum . A library of 88 chalcones were synthesized and evaluated for their in vitro antimalarial activity. Among these, 67, 68, 74, 77, and 78 exhibited good in vitro antimalarial activity against P. falciparum strains 3D7 and K1 with low cytotoxicity. These chalcones also showed reduction in parasitemia and increased survival time of Swiss mice infected with Plasmodium yoelii (strain N-67). Pharmacokinetic studies indicated that low oral bioavailability due to poor ADME properties. Molecular docking studies revealed the binding orientation of these inhibitors in active sites of falcipain-2 (FP-2) enzyme. Compounds 67, 68, and 78 showed modest inhibitory activity against the major hemoglobin degrading cysteine protease FP-2.

Expression, characterization, and cellular localization of knowpains, papain-like cysteine proteases of the Plasmodium knowlesi malaria parasite.

Papain-like cysteine proteases of malaria parasites degrade haemoglobin in an acidic food vacuole to provide amino acids for intraerythrocytic parasites. These proteases are potential drug targets because their inhibitors block parasite development, and efforts are underway to develop chemotherapeutic inhibitors of these proteases as the treatments for malaria. Plasmodium knowlesi has recently been shown to be an important human pathogen in parts of Asia. We report expression and characterization of three P. knowlesi papain-like proteases, termed knowpains (KP2-4). Recombinant knowpains were produced using a bacterial expression system, and tested for various biochemical properties. Antibodies against recombinant knowpains were generated and used to determine their cellular localization in parasites. Inhibitory effects of the cysteine protease inhibitor E64 were assessed on P. knowlesi culture to validate drug target potential of knowpains. All three knowpains were present in the food vacuole, active in acidic pH, and capable of degrading haemoglobin at the food vacuolar pH (≈5.5), suggesting roles in haemoglobin degradation. The proteases showed absolute (KP2 and KP3) to moderate (KP4) preference for peptide substrates containing leucine at the P2 position; KP4 preferred arginine at the P2 position. While the three knowpains appear to have redundant roles in haemoglobin degradation, KP4 may also have a role in degradation of erythrocyte cytoskeleton during merozoite egress, as it displayed broad substrate specificity and was primarily localized at the parasite periphery. Importantly, E64 blocked erythrocytic development of P. knowlesi, with enlargement of food vacuoles, indicating inhibition of haemoglobin hydrolysis and supporting the potential for inhibition of knowpains as a strategy for the treatment of malaria. Functional expression and characterization of knowpains should enable simultaneous screening of available cysteine protease inhibitor libraries against knowpains for developing broadly effective compounds active against multiple human malaria parasites.